4Initial Phase - StabilizationPsychological First Aid (early to mid- phases)Developed after Hurricane Katrina (National Center for PTSD and the NCTSN)Focus on non intrusive compassionate attitude of the part of cliniciansCore focus of PFA on the practical needs of trauma survivors

5Initial Phase – Stabilization (cont’d.)Consistent with research evidence on risk and resilience following traumaApplicable and practical in field settingsAppropriate for developmental levels across the lifespanCulturally informed and delivered in a flexible manner

6Early to Middle Phase Five Intervention Principles (Hobfoll, et al.)Empirical supportAimed at early to mid- phasesPromotion of a sense of safetyCorrective information to help get a realistic view of the futureInformation about friends and relatives

7Early to Middle Phase (cont’d.)Safety from rumors and sensationalized mediaLeadership must take a role in ensuring accurate information is disseminated and fear is not used for political purposesPsychological organizations may use their voice to guide media and political strategy

8Early to Middle Phase (cont’d.)Exposure to televised images may heighten psychological distressChildren may think the disaster is still occurring

9Promotion of CalmingHigh levels of emotionality and arousal may be common especially in the post-trauma periodHigh levels of arousal may lead to panic symptoms and other non-adaptive responsesMost will return to pre-morbid functioningToolbox of skills:Inoculation trainingBullet these and talk in some detail about the interventions

11Promotion of Calming (cont’d.)Delivery of these interventions can be individual, group or community based. Public Health interventions can be directed at large- scale community outreach programs and media used to disseminate informationTechnology can also be used to disseminate informationAt this point CISD (Critical Incident Stress Debriefing) may actually heighten arousal at a time when you want to dampen it

12Promotion of Calming (cont’d.)Studies have shown CISD is not effective in preventing PTSD and may exacerbate some people’s stress after the traumaRole of positive emotions in coping with stress and trauma includingJoyHumorContentmentlove

13Promotion of Calming (cont’d.)Problem-focused copingPeople may perceive the disaster as one big unmanageable problemBreak it down into manageable chunks, which will help in feeling some sense of control

14Self and Collective EfficacyFollowing a disaster people may be at risk of losing their sense of competency at problem solving which may generalize from the initial trauma to everyday lifeTeaching children emotional regulation skillsCommunity self-efficacy through activities such asReligious activitiesMourning rituals

16Promotion of ConnectednessExtensive research of the importance of social support and sustained attachments to loved ones - OxytocinSalutogenic factors (Antonovsky 1979), such as social support, extend beyond the initial trauma

17Promotion of Connectedness (cont’d.)Fundamental importance to children and adolescentsChurchIdentify those with minimal social supportProvide formalized supportOrganize places for teens to organize under supervised support, etc.

29Cognitive Processing TherapyThe gold standard in Veterans Administration clinicsLook at how beliefs in these domains have been impacted by traumaCommon Trauma-Related Cognitive Distortions:“The world is dangerous”“Events are unpredictable and uncontrollable”

31Cognitive Processing Therapy (cont’d.)12 weekly sessions; mins.; individual and group modality options; PCL every sessionCognitive Restructuring and ExposureCognitive restructuring using thought records centered around domains of safety, trust, power/control, intimacy and esteemExposure done through writing about the experience, reading it in session and reading it in between sessions

32Prolonged Exposure Overall aim is to emotionally process the traumaIncludes the following proceduresEducation about most common reactionsBreathe retrainingIn vivo exposure to avoided situations or placesRepeated prolonged imaginal exposure to trauma memories

34Acceptance and Commitment TherapyOrigins in functional contextualism and Relational Frame TheoryFC – focuses on the function that a behavior serves as opposed to the actual behavior and how effective that behavior is in moving toward an identified goalRFT – the building of associations; thoughts and feelings can assume meaning and qualities by being associated with one anotherACT works on the assumption that a certain amount of pain is part of being human and is unavoidable“Pain is inevitable but suffering is optional”Why do we suffer?Experiential avoidance + cognitive fusionRFT – This association is helpful in understanding why thoughts and feelings can trigger pain and then avoidance;-Simple example with trauma- a victim of assault may now associate a knife with danger and pain, even having a mental image of a knife can elicit an intense sense of danger and pain. This individual now may do everything in his power to avoid any thoughts related to knives to avoid the discomfort associated with this image.Pain vs Suffering: Pain is fear, anger, sadness, grief (natural emotions); Suffering is depression, chronic anxiety, loss of relationships, loss of meaning, substance use

35Acceptance and Commitment Therapy (cont’d.)Experiential Avoidance:Misapplied control of internal eventsParadoxical effect of control for internal events: the intensity of thoughts and feelings tend to increase (e.g., don’t think of a yellow jeep)Cognitive Fusion:Thoughts and feelings becomes truths“I am worthless” is only problematic if you believe it to be true and you allow it to stop you from living a valued life (Walser & Westrup 2007)

36Acceptance and Commitment Therapy (cont’d.)Emphasis on living a valued life even with a trauma historyCounters belief that life cannot move forward until unwanted thoughts and feelings are goneImmediate use of value-based actions in goal settingThe goal is not to change the thoughts and feelings but to change your relationship to those thoughts and feelingsCore Components of Acceptance and Commitment Therapy (ACT)

37Acceptance and Commitment Therapy (cont’d.)ValuesThe blueprint for what we want our life to stand forProcess is not a destination, i.e. like the North starMindfulness/Present MomentBeing in the present moment without judgmentHumans tend to spend most of their time in the past or the future

38Acceptance and Commitment Therapy (cont’d.)Cognitive DefusionIncorporates mindfulness“I notice that I’m having the thought that…”Programming: Two Computers MetaphorTechniques: Taking your mind for a walkAcceptance/WillingnessLetting go of the struggle (Tug-Of-War exercise)Willingness to have unwanted thoughts or feelings (Eyes On exercise)What Willingness is notStudies on the utility of Mindfulness

39Acceptance and Commitment Therapy (cont’d.)Self as ContextIf I am not my thoughts and feelings then who am I?Self as content versus self as contextI am my thoughts and feelings versusI am a context upon which thoughts and feelings occurChess Board metaphor

41Acceptance and Commitment Therapy (cont’d.)ACT, the trauma program at Vallejo, is an eight-week closed groupEach week a new process is introducedPatients commit to attend all 8 sessionsFacilitated by 2 therapistsGroup guidelines include an agreement to not discuss the details of their trauma (different to CPT, et al.)Exposure not directly addressed but inherent part of the process